Case #584

Division of DRG's 209G and 209F '

Added by Hanne Osnes-Ringen over 2 years ago. Updated over 1 year ago.

Status:AcceptedStart date:2018-01-26
Priority:MajorSpent time:-
Assignee:Hanne Osnes-Ringen
Target version:Target version 2019
Initiator:Norway Target year:2019
Case type:Major Owner / responsible:
MDC:MDC08 Old forum status:
Target Grouper:COMMON


The case concerns 2 problems with ankle and knee replacements, both first time implant and second time revision.
1. DRG 209G Ankle or knee replacement includes both ankle and knee replacements. There are different costs for these procedures and we would therefore like to split the DRG 209G in two new DRGs. The ankle procedures are mainly done in a few hospitals which also indicate a need of a split here.

i. DRG 209G1: Ankle replacement cost: 100 000,- volume: about 170
ii. DRG 209G2: Knee replacement cost: 70 000,- volume: about 6000

2. The case concerns DRG 209F “Utskifting av protese i kne eller ankel” (Secondary prosthetic replacement in knee or ankle joint) which includes clinically heterogeneous patient groups despite mainly similar procedures. The main reason for the proposal is the difference in the cause of surgery which again creates economical heterogeneity within the group. There is a cost difference depending on the main diagnosis. Patients with infections (T84.5 Infeksjon og betennelsesreaksjon som skyldes innvendig leddprotese) who need a secondary prosthetic ankle or knee replacement have about double both length of stay in hospital and costs than patients undergoing surgery because of mechanic complications (T84.0 Mekaniske komplikasjoner ved innvendig leddprotese).
We would also like to solve another problem with our reconstruction knee prosthesis which are special replacements used mainly in cancer and trauma patients, and represent only a few cases a year. These patients have about the same time of stay in hospital as the patients undergoing surgery because of infection and can therefore be included in the same DRG as these patients.

Costs and length of stay in hospital:

1. Anklereplacement revision with diagnostic code T84.0 Mechanic complications Average costs: 105 000 Days in hospital: 3,5
2. Anklereplacement revisions with the diagnostic code T84.5 Infection Average costs: 394 000 Days in hospital: 41 (few patients)

3. Kneereplacement revisjons with diagnostic code T84.0 Mechanic complications Average costs: 150 000 Days in hospital: 4,7

4. Kneereplacement revisjons with diagnostic code T84.5 Infection Average costs: 305 000 Days in hospital: 17,5

Therefore we would like to split the DRG 209F into two new DRGs:
1. 209F1 Utskifting av protese i kne eller ankel” (Secondary prosthetic replacement in knee or ankle joint)
Most of the revisions, including mechanic complications and most other causes except for the ones mentions below in the “complicated” category
2. 209F2 Komplisert utskifting av protese i kne eller ankel” (Complicated secondary prosthetic replacement in knee or ankle joint)
Including revisions for infections and the reconstruction prosthesis

Technical changes will be added.

Technical changes_case 584.xls (115 KB) Anja Fagervold, 2018-01-30 15:44

Technical changes case #583 & #584 .xlsx (59.5 KB) Martti Virtanen, 2018-12-19 12:11


#2 Updated by Kristiina Kahur over 2 years ago

Finnish National DRG-Centre 8-2-2018

1. Problem with DRG 209G
DRG 209G is a very homogenous group, V% 26%. There are 34 ankle cases out of 3994 cases which cost ca twice as much as the knee cases. However, if to remove 5% of the cases from expensive end, only 2 ankle cases remain among 95% of the cases. The separate group for ankle cases would be too small (# 34) and they would be most probably cost-outliers anyway.

2. Problem with DRG 209F
The current suggestion seems to be an atypical way to split a DRG. If there is a need to create a split based on complications, the CC analysis should be carried out probably.
To make a separate DRG based on one main diagnosis code only seems too narrow approach. In ICD10 there are more complication codes under T84 which should be analyzed from cost/LOS point of view.
Given that in Finland T840 and T845 are coded as main or secondary diagnosis when the secondary prosthetic replacement is under question, it would be complicated to get the right cases into right DRG if the suggested change would be introduced.
Based on Finnish data, DRG 209F is quite homogenous, V% 58% (after trimming 1% of the cases -> 48%). However, there are two peaks within the DRG, but the analysis shows that this is not depending on presence of infection (T84.5). To analyze the reason we would need more time.
Having said that, we do not support the change but we would be interested in analyzing the case further.

#3 Updated by Ralph Dahlgren over 2 years ago

2018-03-01 Ralph Dahlgren
When it comes to the first Norwegian problem to split ankle and knee replacement there are not enough cases to make a split since Sweden only has 29 ancle cases and this is to small of a Group to get a new DRG.
When it comes to the second problem Sweden does not after looking at data want any change in Sweden.

#4 Updated by Martti Virtanen over 2 years ago

  • File Technical changes case #583 & #584.xlsx added
  • Subject changed from Revision of DRG 209G and 209F Knee or ankle replacements, first time and revision to Division of DRG's 209G and 209F '

2018-03-06 Martti Virtanen
This case is closely related to case #583 and therefore the technical changes are combine.
The cases are technically simple.
If done in a slightly modified way, it will not affect other versions and can be used in Norway in so decided.
For this reason the properties have to be used only for Norway The 08S93 may not be changed, instead we use two new properties 08O50 and 08O51. Logically 08O52 is used for case #854. The added diagnosis property is 08X80. For details see technical changes.
There are two codes in the proposal NFC74 and NFC76 that have been removed from CSP-NOR 2016/12/31, in principle they must not be included in Nor defintion tables. They are anyway linked to NFSC99 as the other codes at issue.
The issue of a diagnosis indicating complex situation is a model that NordDRG uses at several occasions. This is however not a true CC-rule.

#5 Updated by Martti Virtanen over 1 year ago

2018-03-13 Expert group
Expert group accepted the proposed changes only affecting NordDRG Nor.

#6 Updated by Martti Virtanen over 1 year ago

  • File deleted (Technical changes case #583 & #584.xlsx)

Also available in: Atom PDF